With increased awareness of the impact of the lymphatic system on all other systems of the body, there are now multitudes of research studies on lymphedema and thus new approaches and treatments by the medical profession. These include medications, prevention, detection, surgery, and regeneration. Despite cursory education on the lymphatics in medical school, research in the United States and elsewhere has managed to progress treatment.

Prevention is always preferred when dealing with disease processes, of course. First, the potential for lymphedema to occur must be recognized. Education of practitioners and experience are keystones. The potential for lymphedema to occur after any type of surgery, trauma, radiation, and disease processes should be explained to the patient. Vigilance, by both patients and their caregivers, can be augmented by tests such as bioimpedance, lymphoscintigraphy, magnetic resonance imaging, and computed tomography scans. Precautions to prevent triggering the onset of lymphedema are available at lymphnet.org and include activity modifications such as use of a prophylactic garment for high-risk activities, avoidance of overheating, protection of skin from trauma or burns, and meticulous hygiene.

Direct and Indirect Surgical Treatment of Lymphedema

Lymphedema can be surgically addressed by direct reconstruction via anastomosis or by indirect reconstruction. Direct repair can mean connecting lymph vessels to veins, connecting non-working lymph vessels to a functioning lymphatic vessel, or using a vein graft to connect two lymph vessels. Studies indicate that all surgical procedures are most successful if they are completed in the early stage of lymphedema.

Indirect repair via free lymph node transfer surgery has become a more frequent solution to lymphedema. These procedures are more successful in patients with secondary lymphedema than in patients with primary lymphedema as a result of the abnormal lymphatic anatomy in congenital lymphedema. These surgical procedures are not widely available because the microsurgery is technically demanding and requires a dedicated, experienced team.

Liposuction can be effective in advanced cases of lymphedema where fat deposition is predominant rather than fluid. Compression garments must be worn 24/7 post surgery.

Debulking surgical procedures remove fat and excess tissue and lobules. As with many surgical procedures, outcomes cannot be guaranteed, and there are real risks for infection, failure to heal, scarring, developing lymphedema in areas of donor node, or no lymphedema benefit.

Medical Treatment of Lymphedema and Ongoing Clinical Trials

Medications have not been an extremely successful area for the treatment of lymphedema. Diuretics are often prescribed, but they can worsen the condition because the protein-rich lymph just becomes more concentrated in proteins and consequently draws more fluid to the area to dilute it. Clinical trials are ongoing for lymphatic growth factors; although success has been seen in animal models, human trials haven’t yet led to treatment. Other countries support the use of coumarin, but liver toxicity concerns prevent its use in the United States. A nutritional additive, horse chestnut extract, has been shown to be partially effective and is without side effects. Oral medications are now in human trials for ubenimex (www.eigerle.com), which would be used in conjunction with lymph node transfers. This drug inhibits an inflammatory substance, leukotriene B4, and so prevents inflammation and lymphatic impairment.

Translation of any of this to actual treatment depends on coverage by insurance. As I sit typing this in the days before New Year’s Day 2018, the Lymphedema Treatment Act has yet to pass in Congress. However, it has been the most supported medical bill! Our patients will need all of us to voice our support as because representatives and senators will need to re-up. Go to lymphedematreatmentact.org now.

See you next month for the ongoing lymphedema saga.

Resources
American Society of Plastic Surgeons. Lymphedema Treatment: Surgical Options. www.plasticsurgery.org/reconstructive-procedures/lymphedema-treatment
Cancer Treatment Centers of America. Surgical Options for Lymphedema. https://www.cancercenter.com/treatments/lymphedema-surgical-options
Lee BB, Laredo J, Neville R. Current status of lymphatic reconstructive surgery for chronic lymphedema: it is still an uphill battle! Int J Angiol 2011;20:73–80. www.ncbi.nlm.nih.gov/pmc/articles/PMC3331640
MD Anderson Cancer Center. Surgical Options for Lymphedema. https://www.mdanderson.org/publications/oncolog/june-2014/surgical-opti…
News Medical. Lymphedema Treatment. https://www.news-medical.net/health/Lymphedema-Treatment.aspx?
Rockson SG. Lymphatic Medicine: Paradoxically and Unnecessarily Ignored. Lymphat Res Biol 2017;15(4):315-6.
Stanford Health Care. Drug Therapies for Lymphedema. https://stanfordhealthcare.org/medical-conditions/blood-heart-circulati…
Stanford Health Care. Surgical Treatment for Lymphedema. https://stanfordhealthcare.org/medical-conditions/blood-heart-circulati…
Stanford Medicine. Study Finds First Possible Drug Treatment for Lymphedema. https://med.stanford.edu/news/all-news/2017/05/study-finds-first-possib…

About the Author
Janet Wolfson is a wound care and lymphedema educator with ILWTI, and Lymphedema and Wound Care Coordinator at Health South of Ocala with over 30 years of field experience.